Full Measure After Hours: The Powerful, Unseen Middlemen Impacting Your Drug Prices

Release Date: October 3, 2024

In this compelling episode of Full Measure After Hours, host Sharyl Attkisson delves deep into the intricate and often opaque world of Pharmacy Benefit Managers (PBMs) — the powerful middlemen influencing prescription drug prices in the United States. Drawing from archival content, Attkisson presents a balanced exploration of PBMs by featuring perspectives from both a critical congressional leader and an industry representative, complemented by poignant personal stories from individuals directly affected by PBMs' practices.

1. Unmasking PBMs: An Insider's Critique

Cheryl Atkisson opens the discussion by highlighting the growing influence of PBMs in the prescription drug ecosystem. She emphasizes the complexity surrounding PBMs and their purported role in managing and reducing drug costs, setting the stage for a critical examination.

Interview with Congressman James Comer of Kentucky ([02:24] - [09:43]):

Congressman Comer offers a scathing critique of PBMs, arguing that these entities, originally intended to act as intermediaries to negotiate lower drug prices, have instead become profit-driven behemoths that inflate costs and manipulate the market.

• Conflict of Interest and Profit Motive: Comer compares PBMs to "tax collectors in the Bible," suggesting that their ability to "charge whatever they wanted" has led to excessive profits. He points out that PBMs have invested in chain and mail-order pharmacies, creating vertical integrations that disadvantage independent pharmacies ([02:24]).

• Lack of Transparency and Political Influence: Highlighting the opaque pricing structures of PBMs, Comer asserts that both major political parties have turned a blind eye to PBMs' malpractices due to substantial political donations from these companies. He states, “When they talk about reforming drug prices, they've been given PBMs a pass.” ([03:41]).

• Systemic Issues and Consumer Harm: Addressing the bureaucratic hurdles imposed by PBMs, Comer recounts how PBMs often deny necessary medications for patients, leading to life-threatening delays. He recounts instances where PBMs reject generic drugs in favor of more profitable brand names, thereby increasing costs and endangering lives ([07:12]).

• Call for Legislative Action: Comer urges Congress to prioritize PBM reforms as the first step toward genuine drug price reductions. He emphasizes the need for transparency and stricter regulations to curb PBMs' unchecked power ([06:56]).

2. Defending PBMs: Industry Perspective

Transitioning to the industry's stance, Attkisson introduces J.C. Scott, President and CEO of the Pharmaceutical Care Management Association (PCMA), who represents PBMs.

Interview with J.C. Scott ([10:08] - [16:37]):

J.C. Scott provides a defense of PBMs, outlining their intended role in the healthcare system and countering the criticisms presented by Comer.

• Role and Value of PBMs: Scott defines PBMs as entities hired by health plan sponsors (employers, Medicare plans) to manage prescription drug benefits. He argues that PBMs are essential in negotiating with drug manufacturers and pharmacies to secure the lowest possible costs for consumers. “PBMs also do a lot in the care management space,” ensuring that patients receive appropriate and safe medications ([11:03]).

• Cost Management and Incentive Structures: Emphasizing that PBMs are motivated to reduce costs, Scott explains that PBMs are often compensated through fee arrangements or percentage-based rewards tied to the savings they achieve for their clients. This structure, he contends, aligns PBMs' interests with those of consumers and employers ([12:33]).

• Addressing Controversies: When confronted with allegations that PBMs contribute to high drug prices, Scott acknowledges the complexity of the pharmaceutical supply chain. He asserts that all stakeholders, including manufacturers, pharmacies, and PBMs, share responsibility for drug affordability. “Every stakeholder within the supply chain has a role in trying to address that affordability challenge.” he states ([14:20]).

• Response to Legislative Proposals: Regarding potential Congressional interventions, Scott advocates for system improvements through technological advancements rather than legislative mandates. He believes that enhancing electronic tools can streamline PBMs' operations and resolve individual cases more efficiently ([16:12]).

3. Personal Toll: Families Affected by PBM Practices

To humanize the debate, Attkisson introduces the heartrending story of Gabriella and Shawn Burst, siblings who recount their mother's tragic battle with cancer and the detrimental delays caused by PBMs.

Testimonial from Gabriella and Shawn Burst ([17:04] - [25:51]):

• Family Impact: Gabriella and Shawn share how their mother's cancer treatment was jeopardized by PBMs' bureaucratic delays. Despite her initial remission, when the cancer relapsed, PBMs hindered timely access to critical medications. “They can take all the time they want essentially to give a response, to respond back to what the doctors are prescribing.” Shawn emphasizes the lack of urgency and regulation in PBMs' processes ([21:43]).

• Emotional and Practical Consequences: The Burst siblings detail how extended delays, sometimes extending weeks, deprived their mother and family of precious time, potentially costing her months of life. Shawn states, “I think we got robbed of at least several months with my mom that we could have made memories and done things with.” ([23:23]).

• Call for Regulation: Highlighting the absence of oversight, the Bursts advocate for mandatory timelines for PBM responses to prescription requests. They suggest that enforcing a 24-hour decision window could prevent life-threatening delays. “There's no one they answer to. There's no regulations in place.” Shawn urges for immediate regulatory reforms to protect patients' access to necessary medications ([25:51]).

4. Concluding Insights

Through incisive interviews and personal narratives, this episode of Full Measure After Hours sheds light on the pivotal yet hidden role of PBMs in the American healthcare system. While Congressman Comer and the Burst siblings illustrate the adverse effects and ethical concerns surrounding PBMs, J.C. Scott counters by defending their essential function in cost management and healthcare delivery.

The episode underscores the urgent need for transparency, regulation, and bipartisan efforts to address the complexities introduced by PBMs. As drug prices continue to soar, understanding and reforming the role of PBMs remain critical to ensuring affordable and timely access to essential medications for all Americans.

Notable Quotes:

• Congressman James Comer ([02:24]): “When you're talking about trying to make pharmaceutical drugs cheaper and you don't look at PBMs, then you're doing a huge disservice to the American people.”

• J.C. Scott ([10:15]): “PBMs also do a lot in the care management space, meaning to help you and I as patients to make sure when we're prescribed a drug that it's not going to interact badly with some other drug that we have to help communicate with our doctor's office.”

• Shawn Burst ([21:31]): “[There's nothing that regulates them, so they kind of have free reign to do what they want once the prescription is in their hands.]”

• Shawn Burst ([25:43]): “[The most important thing is to put some kind of regulation in place to where there's a timeline with they have to respond within 24 hours]”

This episode serves as a crucial resource for listeners seeking to understand the multifaceted dynamics of PBMs and their profound impact on healthcare affordability and patient well-being.